编者按
近日，2024年新加坡GIHep与肝病联合大会（Combined GlHep & SHC 2024）在新加坡举办。来自世界各地的肝病领域专家齐聚一堂，共同探讨肝病的最新进展、挑战与机遇。《国际肝病》记者奔赴现场，对多位专家进行了采访。采访过程中，孟加拉国Enam医学院附属医院助理教授Md Shofequnnabi Rumi医生围绕病毒性肝炎的治疗现状、代谢相关性脂肪性肝病（MAFLD）和肝细胞癌（HCC）等相关内容进行了探讨。
《国际肝病》
目前，慢性丙型肝炎和慢性乙型肝炎的治疗情况如何？
Rumi医生：现在慢性丙型肝炎是可以被治愈的。患者只需接受12至24周的抗病毒治疗，便可以实现疾病缓解或完全治愈。然而，对于慢性乙型肝炎，目前还没有完全治愈的方法。在亚洲和西方国家，人们主要关注的是MAFLD，以前称为NAFLD，或脂肪肝疾病。
Hepatology Digest: What is the current status of treatment for chronic hepatitis C and chronic hepatitis B?
Dr. Rumi: In the modern era, chronic hepatitis C is curable, and if patients receive appropriate treatment for about 12 to 24 weeks, they can achieve remission or complete cure. However, for chronic hepatitis B, there is no curative treatment available. In Asia and Western countries, the main concern has shifted to MAFLD, previously known as NAFLD, or fatty liver disease.
《国际肝病》
在乙肝治疗领域，近年来有哪些新的治疗策略或药物正在研发中，您认为它们对实现乙肝功能性治愈有多大潜力？
Rumi医生：在孟加拉国，治疗慢性乙型肝炎常用三种药物为恩替卡韦（ETV）、替诺福韦艾拉酚胺（TAF）和富马酸替诺福韦二吡呋酯（TDF）。因ETV服用方便且价格便宜，所以临床上我们更倾向使用ETV，这也令更多需长期服药的患者获益。不过，ETV并不能完全治愈患者。目前，新型疗法如NASVAC和其他免疫治疗方法正处于Ⅲ期临床试验阶段，希望这些新的治疗方法能带来更高的功能性治愈率。
Hepatology Digest: In the field of hepatitis B treatment, what new treatment strategies or drugs are currently being developed? How much potential do you think we have in achieving a functional cure for hepatitis B?
Dr. Rumi: In our country, three drugs are commonly used in the treatment of chronic hepatitis B: entecavir, tenofovir alafenamide, and tenofovir disoproxil fumarate. All are available, but we frequently use and prefer entecavir because it is convenient and less expensive. This makes it affordable for patients, and those who take it regularly have good outcomes, though it is not a curative treatment. Currently, newer therapies such as NASVAC and other immune-modulated treatments are in phase III trials, and it is hoped that these new treatment methods can bring higher functional cure rates.
《国际肝病》
HCC的早期诊断和治疗一直是难点，您对此有何建议？
Rumi医生：HCC早期通常无明显症状，许多患者在病情发展到晚期时才到医院求医。若能在早期发现，当肿瘤还很小的时候，患者就有机会接受手术切除或肝移植等治愈性治疗。然而，一旦病情进入晚期，就没有治愈HCC的方法了。因此，我强烈建议对慢性乙型肝炎和丙型肝炎患者进行定期监测。在孟加拉国，自2008年起，所有新生儿都会接种乙肝疫苗，这是国家扩大免疫规划的一部分。但2008年之前出生的人并未接种，因此他们需要被特别关注。
此外，对于慢性肝炎患者，以及有代谢综合征、糖尿病、肥胖、甲状腺功能减退、血脂异常等激素紊乱的患者，我建议定期进行超声检查以评估脂肪肝的情况。当前，MAFLD已成为全球焦点，它是导致肝硬化的一个重要原因。患者可以通过减肥和改变生活方式等措施来预防脂肪肝。
Hepatology Digest: Early diagnosis and treatment of hepatocellular carcinoma have always been difficult. What suggestions do you have for this?
Dr. Rumi: Early liver disease often presents no symptoms, so patients do not seek medical attention until the disease is advanced. If patients visit the doctor at an early stage, with very small tumor sizes, they can undergo resection or liver transplantation, which are curative options. However, when patients present at a late or advanced stage, curative treatment for hepatocellular carcinoma is not yet available. Therefore, I recommend regular surveillance for patients with chronic hepatitis B and C. In our country, since 2008, children receive hepatitis B vaccination after birth, included in the Expanded Program on Immunization (EPI). However, those born before 2008 are not vaccinated against hepatitis B.
I suggest regular routine checkups with simple ultrasound for patients with chronic hepatitis B and C, as well as for those with metabolic syndrome, diabetes mellitus, obesity, or hormonal disorders like hypothyroidism and dyslipidemia, to assess for fatty liver. In the modern era, worldwide, MAFLD is the main concern and leading cause of liver cirrhosis. Patients can prevent fatty liver by taking measures such as weight reduction and lifestyle changes.
《国际肝病》
针对MAFLD向代谢相关脂肪性肝炎（MASH）发展，甚至进一步可能发展为HCC的病程，您认为当前有哪些有效的干预手段？
Rumi医生：MAFLD现已被视为一种组织学上的诊断。当患者体重减轻占其总体重的7%~9%时，MAFLD是可逆的。即使出现纤维化，也可通过减重实现逆转。但是，一旦发展为肝硬化，病情就变得不可逆了。许多因脂肪肝和肝酶水平升高（例如SGPT和SGOT指标上升）而前来咨询的患者，我首先会建议他们改变生活方式，如减重、少吃油腻或高热量食物以及戒酒。
对于患有MAFLD和其他合并症（如糖尿病、血脂异常、甲状腺功能减退或肥胖）的患者，我们经常使用司美格鲁肽。司美格鲁肽不仅有助于患者减轻体重，还能改善高血糖或葡萄糖耐量受损。我近期的研究显示，司美格鲁肽在MAFLD的治疗中确实表现出了其益处。对于已经出现纤维化的MAFLD患者，我们考虑使用FXR激动剂和其他新型药物，尽管这些药物的具体疗效仍在进一步的研究之中。
Hepatology Digest: Regarding the progression of MAFLD to MASH and potentially further to hepatocellular carcinoma, what effective intervention methods do you think are currently available?
Dr. Rumi: MAFLD is now recognized as a histological diagnosis. MAFLD is reversible when patients reduce their weight by about 7 to 9 percent of their total body mass. Even fibrosis can be reversed with weight reduction. However, once a patient develops cirrhosis, it becomes irreversible. Many patients come to me with fatty liver and elevated liver enzyme levels, such as SGPT and SGOT. The first recommendation is lifestyle modification, including weight reduction, avoiding fatty foods, and abstaining from alcohol. For patients with MAFLD and other comorbidities like diabetes mellitus, dyslipidemia, hypothyroidism, or obesity, we often use semaglutide. Semaglutide helps with weight reduction and improves hyperglycemia or impaired glucose tolerance. My recent observation is that semaglutide is beneficial. For patients with fibrosis, we can use FXR agonists and other newer drugs, although their benefits are still under study.
